In a new book, author Anne Fletcher reveals the good and the bad state of care in drug rehab facilities.

Last summer, the National Center on Addiction and Substance Abuse at Columbia University released a report detailing the devastating state of addiction treatment. The bottom line: counselors with little education and less oversight are using outdated and sometimes harmful techniques; there are no national standards for credentialing or training counselors and most treatment centers, even those with extensive financial resources, do not always use best practices. In her book Inside Rehab Fletcher investigates the erratic quality of care in some of these facilities and how some centesr are working to improve treatments. (Disclosure: I was interviewed and cited in the book on the subject of rehabilitation for teens).

Why did you decide to investigate rehab?

There’s a huge number of people with serious substance use disorders (SUD) and 22 million people in this country who have problems. Only 1 in 10 of them go for any sort of help each year. There’s all kinds of reasons why the other 9 don’t get help but it’s my impression that many people who don’t get help … are not happy with the treatment options out there.

The public is greatly misinformed. They don’t know anything about rehab. There’s so much misinformation, so I thought that somebody needs to go inside and explain it to the public and talk to people who’ve been there so that’s what I did.

What was the most surprising thing you found?

The biggest shocker to most people is the lack of training of the people who provide the lion’s share of treatment, addiction counselors. In many states, they are not even required to have a college degree.

Any other big surprises?

I knew that addiction treatment is largely group-based but in visiting some of the high end programs where I thought maybe it would be more individualized, I [found the same thing]. I actually added it up and went through a typical treatment day. It works to be about 8 hours of day of seat time [in groups] and this is when you are paying $25,000-30,000 a month. I had figured that there would be more than three to five hours of individual [counseling time] a week, at least.

So there were 8 hours a day of group or watching videos or lectures— and that has been found to be among the least effective treatments for alcohol problems. I really didn’t expect that much seat time. I visited outpatient treatment as well and some of those have no individual [sessions] at all or it is ‘as needed’ and even less than in the residential treatment.

One of the things I found myself thinking as I was sitting in those programs was, ‘Whoever came up with a model where you take addicts and they are sitting for three hours or more three times a week or longer in group based treatment, talking about the program?’ That’s an awfully long time to just sit on your butt. I would ask, ‘Is there any evidence that this is effective?’ and no one could answer where it came from.

Can’t you admit more people and charge more when you put them in groups than if you individualize therapy?

It is cheaper. In all honesty, however, the places that I visited I really believe in what they’re doing. There are some incredibly compassionate people who believe they are providing the best treatment and they’re helping a lot of people.

What else did you find that was disturbing?

One of the things that really floored me was the resistance to using maintenance treatments [with methadone or suboxone] on the part of programs, when the literature is so clear that maintenance is the most effective treatment for people with opioid addictions. I had places say to me ‘We don’t use it because it’s a recipe for failure’ and it floors me that anyone can think that way [given the overwhelming data].

A lot of addiction treatment in America is based on the idea that you have to “break” addicts, humiliate them and confront them until they confess their worst sins. Is it effective?

I didn’t personally observe anything terrible. I kind of expected I might see some confrontation, but I didn’t see any overt confrontation. But the vestiges of that confrontational approach remain in the words that are used to describe people, like the stereotype that all addicts are selfish and manipulative and always lying, that they’re all the same.

The worst thing I heard reported, and I did not observe this, but I was told about a place that treated indigent people, which was loving and caring [in the treatment itself.] But at night, [the participants] lived in sober homes and had to sit on boxes in the corner or wear [humiliating and degrading] signs around their neck, and that occurred in 2010. It’s still going on, including [the groups where] one person sits in the center of the circle [to be] shamed [by everyone else].

There’s also a lot of pressure to emphasize very personal information in group, a lot of pressure to disclose secrets. While some people said that was very helpful, some said it was very unhelpful. Someone did talk about having to disclose sexual information in a group situation and was very uncomfortable with that and did better in individual therapy. The problem is the lack of an individualized approach and not recognizing that everyone doesn’t belong in a group.

What about the 12-step approach, another common program in drug rehab centers. Is it effective?

We need to move away from the one size fits all model. We know the 12 steps don’t work for many people. Fifty percent to 80% of people sent to [Alcoholics Anonymous] from treatment drop out within a year. Yeah, it’s great when it works and it works for people who affiliate and get involved, but most people drop out and they’re not being told about other options.

So, do we have treatments for the variety of people who need it?

One of biggest issues is that of those 22 million people with substance use disorders, the vast majority are not the kinds of people who belong in an addiction treatment program [as they are configured today]. The vast majority of people with SUD do not have severe addictions. There’s no place for these people and they often do wind up [in rehabs] and don’t fit and drop out or keep using until it does get really bad.

We need to better educate all of our health and mental health professionals about SUD. Most people are blown away [to learn that] most psychologists don’t have any training in addictions Our physicians have very little training in identifying SUD, let alone treatment. And we need to improve the training of people working in the field itself. Most experts said that they thought that the minimum credential, as it is in most psychology [fields], should be a master’s degree, with the ability to critically review scientific literature and think critically.

Where should someone who needs help for an alcohol or other drug problem turn to for treatment?

First of all, I would suggest that if you can, get an independent evaluation from someone who doesn’t have any vested interest in any program you’re considering.

The first knee jerk reaction is that ‘You gotta go to rehab.’ But if someone doesn’t have a severe life threatening addiction, for starters, find an individual therapist with mental health experience who also has experience with addiction.

If you are going to go for help, don’t automatically think residential. There are a very small number of people who really need residential, typically people with serious co-occurring disorders who have been through outpatient and failed many times.

What positive things did you find?

Number one, the compassion in the field. They really believe and really want to help people. But number two, I did feel that things are changing and even among the programs I visited they were changing over time. I do think things are changing in a positive way towards evidence-based treatment but it’s slow and spotty.